Flores, Ian Patrick Gabriel F.

II - 3 General Objective: Given 20 minutes to visit a family with a father who needs maintenance of health, the nurse should be able to provide quality care utilizing the nursing process.

Specific Objective 1.Establish Rapport

2. Gather Pertinent information

3. Perform Complete Assessment

Activities Magandang umaga po ako po si Nurse Ian at ako ho ay nakadestino sa UST Hospital Clinical Division Outpatient Department. Kasama ko po si Nurse Marian at kami po ay naririto upang makipagtulungan sainyo na mapaunlad ang inyong buhay pangkalusugan. Nasa UST-OPD ho kami tuwing Martes, mula alas otso ng umaga hanggang alas dos medya ng hapon. Simula ngayon ho hanggang Enero 28 e naroon hu kami. Naririto po kami upang makipagtulungan sa inyong buhay pangkalusugan. Name: Jose Delumin Age: 47 Adress: 1212 Sta. Clara St, Sampaloc, Manila Civil Status: Married Occupation: Janitor at CEU Religion: Roman-Catholic Hair: Well distributed, well groomed, black in color, no signs of pediculosis Eyes: Not wearing any glasses, possible presbyopia (loss of near vision) Ears: Has both, no discharge, possible presbycusis Nose: No discharge, symmetric Lips: Not dry, pink in color Teeth: Yellowish-White in color Throat: No sore throat Chest: Symmetrical Abdomen: Slightly rounded Extremities: Symmetrical, complete Skin: Fair complexion, good skin turgor Emotional: Vaillants Theory of Emotional Health - Emotional health, a sense of resilience, pragmatism and dependability,

being close to ones siblings Social: Eriksons Integrity versus Despair Individuals recognize that they are reaching the end of life. If they can take satisfaction in having led a successful life they will experience integrity. Mental: Multidimensionality - Cognitive mechanics: the hardware of the mind Speed and accuracy of processes involved in sensory input, attention, visual and motor memory, discrimination, comparison, and categorization PR 60-100 RR 12-20 BP 110/70 to 120/80 Temp . . Wellness maintenance, overcrowding, susceptibility to chronic diseases

4. Identify Health needs/ problems

5. Scoring: Problem Wellness maintenance Overcrowding Susceptibility to chronic diseases

Nature 0.66 1 0.66

Modifiability 0.66 0 0.66

Preventive Potential 1 0.5 1

Salience 0.33 1 0.33

Total 2.65 2.5 2.65

6. Plan appropriate Nursing Intervention Intervention 1. Determine individual strengths and skills of the client 2. Determine age and developmental issues and presence of medical conditions 3. Provide accurate and relevant information regarding current and future needs 4. Promote clients participation in problem identification and decision making

Rationale To establish comparative baseline for potential growth and/or modifications in current strategies To know what interrupts the clients ability to meet own needs

For the client to incorporate into self-care plans while minimizing problems associated with change To optimize outcomes and to support health promotion

5. Active-listen clients concerns 6. Evaluate for substance use or abuse 7. Determine level of adaptive behaviour, knowledge, and skills about health maintenance, environment, and safety 8. Evaluate environment 9. Encourage socialization and personal involvement 10. Refer to social services, as indicated 7. Implement Planned Nursing Intervention

To exhibit regard for clients values and beliefs, and support positive responses To affect clients desire and ability to help self To determine beginning point of planning and interventions to assist client in addressing needs

To note individual adaptation needs To enhance support system, provide pleasant stimuli, and prevent permanent regression For financial support, housing or legal concerns

8. Evaluate the outcome of the nursing intervention